毒蛇（蝮蛇）咬伤患者预后影响因素分析
发布时间：2019-05-22 18:44
【摘要】：目的研究中西医结合治疗毒蛇咬伤的方法及与影响毒蛇咬伤患者预后有关的独立危险因素,为提前判断患者预后及规范临床诊治提供理论依据。方法回顾性分析2013年4月~2014年11月,安徽中医药大学第一附属医院急诊科病房收治的232例毒蛇咬伤患者的一般资料及临床指标,入选病例标准参照2011年中医外科学术年会制定的中西医结合治疗毒蛇咬伤的评分及诊断国际标准[1]。根据患者出院前最后一次复查的血常规、凝血常规、心肌酶、肝酶、肾功能、炎症指标等实验室指标及毒蛇咬伤患者症状与体征评分,将患者分为好转组(81例)、痊愈组(151例),对两组患者的临床资料进行单因素分析,计量资料进行两独立样本t检验,计数资料采用?2检验,再将可能影响预后的危险因素逐步引入logistic回归分析,P0.05的危险因素进入回归模型,得出独立危险因素与logistic回归方程,并检验回归模型显著性。最后对独立危险因素绘制受试者工作特征曲线(ROC曲线),通过ROC曲线分析各指标在预测毒蛇咬伤患者病情轻重及预后上的价值。结果1.好转组:包括出院前最后一次复查的血清酶学指标未完全恢复正常,但未达到MODS诊断标准,全身与局部症状明显减轻、伤口基本愈合、积分指数为30%~89%的患者。共81例(34.9%),其中男性44例(54.3%),女性37例(45.7%),平均年龄(68.3±9.3)岁;痊愈组:包括复查的血清酶学指标在正常范围内,全身与局部症状消失、伤口愈合、伤肢功能恢复、积分指数≥90%的患者。共151例(65.1%),男性81例(53.6%),女性70例(46.4%),平均年龄(50.4±15.6)岁。两组患者的的性别无统计学意义,年龄存在显著差异(P0.01)。2.临床观察指标:毒蛇咬伤好转组患者与痊愈组患者比较,丙氨酸氨基转移酶[(45.6±17.9)U/L vs(38.7±13.4)U/L P0.01],天门冬氨酸氨基转移酶[(57.1±13.2)U/L vs(46.8±15.8)U/L P㧐0.05],尿素氮[(21.4±9.7)mmol/L vs(18.5±11.3)mmol/LP㩳0.05],血肌酐[(234.7±132.4)μmol/L vs(12.4±63.6)μmol/L P㧐0.05],肌酸激酶[(368.4±163.5)U/L vs(228.9±136.7)U/L P0.01],肌酸激酶同工酶[(23.9±13.4)U/L vs(18.9±5.7)U/L P0.01],总胆红素[(15.7±6.6)μmol/L vs(18.9±5.7)μmol/L P㩳0.05],超敏C-反应蛋白[(23.7±11.4)mg/L vs(16.67±4.69)mg/L P㧐0.05],乳酸脱氢酶[(183.4±51.7)U/L vs(134.5±22.1)U/L P㧐0.05],白细胞计数[(14.9±5.4)×109/L vs(13.7±4.3)×109/L P㩳0.05],凝血酶原时间[(15.8±3.7)s vs(15.3±2.9)s P㧐0.05],部分凝血酶原时间[(41.5±13.7)s vs(39.8±12.1)s P㧐0.05]。3.单因素分析结果显示:两组毒蛇咬伤患者的年龄、丙氨酸氨基转移酶、尿素氮、肌酸激酶、肌酸激酶同工酶、总胆红素、白细胞计数,7个指标间差异有统计学意义(均P0.05);天门冬氨酸氨基转移酶、血肌酐、超敏C-反应蛋白、乳酸脱氢酶、凝血酶原时间、部分凝血酶原时间在两组差异中无统计学意义(均P0.05)。4.与预后相关的多因素分析:根据单因素分析的结果,选取其中P0.05的7个可能影响毒蛇咬伤患者病情及预后的危险因素根据临床检验标准赋值后引入Logistic回归。以0.05为剔除变量的显著性水准,最后进入回归方程的危险因素有:年龄(60岁)、丙氨酸氨基转移酶(50 U/L)、肌酸激酶同工酶(24U/L)。5.毒蛇咬伤预后的危险因素的ROC曲线下面积分别为:年龄0.895,丙氨酸氨基转移酶0.842,肌酸激酶同工酶0.858。6.年龄,丙氨酸氨基转移酶,肌酸激酶同工酶预测效能分析:最佳截断值分别为61.4岁60U/L 27U/L;灵敏度分别为82.7%63.0%71.6%;特异度分别为84.1%95.4%96.7%;约登(Youden)指数分别为0.6682 0.5833 0.6829?结论单因素分析显示天门冬氨酸氨基转移酶、血肌酐、超敏C-反应蛋白、乳酸脱氢酶、凝血酶原时间、部分凝血酶原时间为影响毒蛇咬伤患者预后的非危险因素;年龄、丙氨酸氨基转移酶升高、尿素氮升高、肌酸激酶升高、肌酸激酶同工酶升高、总胆红素升高、白细胞计数增多为影响毒蛇咬伤患者预后的危险因素。多因素logistic回归分析显示患者年龄(60岁)、丙氨酸氨基转移酶(50 U/L)、肌酸激酶同工酶(24U/L)这3个变量进入回归模型,是影响毒蛇咬伤患者预后的独立危险因素。
[Abstract]:Objective To study the method of the combination of traditional Chinese and western medicine in the treatment of venomous snake bite and the independent risk factors related to the prognosis of the patients with venomous snake bite. Methods The general data and clinical indicators of 232 venomous snake bite patients were analyzed retrospectively from April 2013 to November 2014 in the first Affiliated Hospital of Anhui University of Traditional Medicine. The selected case standard refers to the scoring and diagnosis international standard[1] of the Chinese and western medicine combined with the traditional Chinese and western medicine for the treatment of venomous snake bite in 2011. The patients were divided into the improvement group (81 cases) and the recovery group (151 cases) according to the blood routine, the blood routine, the blood routine, the myocardial enzyme, the liver enzyme, the renal function, the inflammation index and other laboratory indexes before the discharge of the patient and the symptoms and the sign scores of the venomous snake bite patients. The clinical data of two groups of patients were analyzed, and two independent samples of t-test and counting data were used to count the data. 2. The risk factors that could affect the prognosis were gradually introduced into the logistic regression analysis, and the risk factors of P0.05 were introduced into the regression model, and the independent risk factors and the logistic regression equation were obtained, and the significance of the regression model was examined. Finally, the working characteristic curve (ROC curve) of the subject was drawn on the independent risk factors, and the value of each index in predicting the severity and the prognosis of the venomous snake bite was analyzed by the ROC curve. Results 1. The improvement group: The serum enzyme study index, including the last review before discharge, did not return to normal, but did not reach the MODS diagnosis standard, the whole body and the local symptoms were significantly reduced, the wound basically healed, and the integral index was 30% to 89% of the patients. A total of 81 cases (34.9%) were male, including 44 (54.3%),37 (45.7%), mean age (68.3, 9.3), and the recovery group: including the reexamination of the serum enzymic index in the normal range, the disappearance of the whole body and the local symptoms, the healing of the wound, the recovery of the function of the injured limb, The integration index was 90% of the patients. There were 151 (65.1%),81 (53.6%),70 (46.4%) and average (50.4, 15.6) years. There was no significant difference in the sex of the two groups (P0.01). Clinical observation index: compared with the recovery group, alanine aminotransferase[(45.6-17.9) U/ L vs (38.7-13.4) U/ L P0.01], aspartate aminotransferase[(57.1-13.2) U/ L vs (46.8[15.8) U/ L P-0.05], urea nitrogen[(21.4-9.7) mmol/ L vs (18.5[11.3) mmol/ L-0.05], [(234.7-132.4) umol/ L vs (12.4-63.6). mu.mol/ L P-0.05], creatine kinase[(368.4-163.5) U/ L vs (228.9-136.7) U/ L P0.01], creatine kinase isoenzyme[(23.9-13.4) U/ L vs (18.9-5.7) U/ L P0.01], total bilirubin[(15.7-6.6). mu.mol/ L vs (18.9-5.7). mu.mol/ L P-0.05], hypersensitive C-reactive protein[(23.7-11.4) mg/ L vs (16.67-4.69) mg/ L P-0.05], lactate dehydrogenase[(183.4-51.7) U/ L vs (134.5-22.1) U/ L P-0.05], white blood cell count[(14.9-5.4)[109/ L vs (13.7[4.3)[109/ L] P-0.05], prothrombin time[(15.8[3.7) s vs (15.3[2.9) s P-0.05], Partial thromboplastin time[(41.5-13.7) s vs (39.8-12.1) s P-0.05].3. The results of single factor analysis showed that the age, alanine aminotransferase, urea nitrogen, creatine kinase, creatine kinase isoenzyme, total bilirubin, white blood cell count and 7 indexes of the two groups of venomous snake bite were statistically significant (all P0.05); and the aspartate aminotransferase, There was no significant difference between the two groups (P0.05). Multi-factor analysis related to prognosis: according to the results of single factor analysis,7 of the risk factors that may affect the condition and prognosis of the patients with venomous snake bite may be selected according to the result of single factor analysis. Logistic regression is introduced according to the value of clinical test standard. The risk factors of the regression equation were: age (60 years), alanine aminotransferase (50U/ L) and creatine kinase isoenzyme (24U/ L). The area under the ROC curve of the risk factors for the prognosis of the venomous snake bite were: age 0.895, alanine aminotransferase 0.842, and creatine kinase isoenzyme 0.858.6. The best cut-off values were 61.4 and 6U/ L 27U/ L, the sensitivity was 82.7% 63.0% 71.6%, the specificity was 84.1% 95.4% 96.7%, and the denden index was 0.6682 0.5833 0.6829, respectively. Conclusion The single-factor analysis shows the non-risk factors of the prognosis of the patients with the venomous snake bite, including the aspartate aminotransferase, the blood myocarcin, the hypersensitive C-reactive protein, the lactate dehydrogenase, the prothrombin time and the partial thromboplastin time. The increase of urea nitrogen, the increase of creatine kinase, the increase of the isoenzyme of creatine kinase, the increase of total bilirubin and the increase of white blood cell count are the risk factors that affect the prognosis of the patients with venomous snake bite. Logistic regression analysis of multiple factors showed that the three variables of age (60 years), alanine aminotransferase (50 U/ L) and creatine kinase isoenzyme (24U/ L) entered the regression model, which was an independent risk factor that affected the prognosis of the patients with venomous snake bite.
【学位授予单位】：安徽中医药大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R269
本文编号：2483158
[Abstract]:Objective To study the method of the combination of traditional Chinese and western medicine in the treatment of venomous snake bite and the independent risk factors related to the prognosis of the patients with venomous snake bite. Methods The general data and clinical indicators of 232 venomous snake bite patients were analyzed retrospectively from April 2013 to November 2014 in the first Affiliated Hospital of Anhui University of Traditional Medicine. The selected case standard refers to the scoring and diagnosis international standard[1] of the Chinese and western medicine combined with the traditional Chinese and western medicine for the treatment of venomous snake bite in 2011. The patients were divided into the improvement group (81 cases) and the recovery group (151 cases) according to the blood routine, the blood routine, the blood routine, the myocardial enzyme, the liver enzyme, the renal function, the inflammation index and other laboratory indexes before the discharge of the patient and the symptoms and the sign scores of the venomous snake bite patients. The clinical data of two groups of patients were analyzed, and two independent samples of t-test and counting data were used to count the data. 2. The risk factors that could affect the prognosis were gradually introduced into the logistic regression analysis, and the risk factors of P0.05 were introduced into the regression model, and the independent risk factors and the logistic regression equation were obtained, and the significance of the regression model was examined. Finally, the working characteristic curve (ROC curve) of the subject was drawn on the independent risk factors, and the value of each index in predicting the severity and the prognosis of the venomous snake bite was analyzed by the ROC curve. Results 1. The improvement group: The serum enzyme study index, including the last review before discharge, did not return to normal, but did not reach the MODS diagnosis standard, the whole body and the local symptoms were significantly reduced, the wound basically healed, and the integral index was 30% to 89% of the patients. A total of 81 cases (34.9%) were male, including 44 (54.3%),37 (45.7%), mean age (68.3, 9.3), and the recovery group: including the reexamination of the serum enzymic index in the normal range, the disappearance of the whole body and the local symptoms, the healing of the wound, the recovery of the function of the injured limb, The integration index was 90% of the patients. There were 151 (65.1%),81 (53.6%),70 (46.4%) and average (50.4, 15.6) years. There was no significant difference in the sex of the two groups (P0.01). Clinical observation index: compared with the recovery group, alanine aminotransferase[(45.6-17.9) U/ L vs (38.7-13.4) U/ L P0.01], aspartate aminotransferase[(57.1-13.2) U/ L vs (46.8[15.8) U/ L P-0.05], urea nitrogen[(21.4-9.7) mmol/ L vs (18.5[11.3) mmol/ L-0.05], [(234.7-132.4) umol/ L vs (12.4-63.6). mu.mol/ L P-0.05], creatine kinase[(368.4-163.5) U/ L vs (228.9-136.7) U/ L P0.01], creatine kinase isoenzyme[(23.9-13.4) U/ L vs (18.9-5.7) U/ L P0.01], total bilirubin[(15.7-6.6). mu.mol/ L vs (18.9-5.7). mu.mol/ L P-0.05], hypersensitive C-reactive protein[(23.7-11.4) mg/ L vs (16.67-4.69) mg/ L P-0.05], lactate dehydrogenase[(183.4-51.7) U/ L vs (134.5-22.1) U/ L P-0.05], white blood cell count[(14.9-5.4)[109/ L vs (13.7[4.3)[109/ L] P-0.05], prothrombin time[(15.8[3.7) s vs (15.3[2.9) s P-0.05], Partial thromboplastin time[(41.5-13.7) s vs (39.8-12.1) s P-0.05].3. The results of single factor analysis showed that the age, alanine aminotransferase, urea nitrogen, creatine kinase, creatine kinase isoenzyme, total bilirubin, white blood cell count and 7 indexes of the two groups of venomous snake bite were statistically significant (all P0.05); and the aspartate aminotransferase, There was no significant difference between the two groups (P0.05). Multi-factor analysis related to prognosis: according to the results of single factor analysis,7 of the risk factors that may affect the condition and prognosis of the patients with venomous snake bite may be selected according to the result of single factor analysis. Logistic regression is introduced according to the value of clinical test standard. The risk factors of the regression equation were: age (60 years), alanine aminotransferase (50U/ L) and creatine kinase isoenzyme (24U/ L). The area under the ROC curve of the risk factors for the prognosis of the venomous snake bite were: age 0.895, alanine aminotransferase 0.842, and creatine kinase isoenzyme 0.858.6. The best cut-off values were 61.4 and 6U/ L 27U/ L, the sensitivity was 82.7% 63.0% 71.6%, the specificity was 84.1% 95.4% 96.7%, and the denden index was 0.6682 0.5833 0.6829, respectively. Conclusion The single-factor analysis shows the non-risk factors of the prognosis of the patients with the venomous snake bite, including the aspartate aminotransferase, the blood myocarcin, the hypersensitive C-reactive protein, the lactate dehydrogenase, the prothrombin time and the partial thromboplastin time. The increase of urea nitrogen, the increase of creatine kinase, the increase of the isoenzyme of creatine kinase, the increase of total bilirubin and the increase of white blood cell count are the risk factors that affect the prognosis of the patients with venomous snake bite. Logistic regression analysis of multiple factors showed that the three variables of age (60 years), alanine aminotransferase (50 U/ L) and creatine kinase isoenzyme (24U/ L) entered the regression model, which was an independent risk factor that affected the prognosis of the patients with venomous snake bite.
【学位授予单位】：安徽中医药大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R269
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